Olivier Rosello

Outcomes of Gartland type III supracondylar fractures treated using Blount's method

BACKGROUNDnSupracondylar fractures of the elbow with major displacement are usually treated by surgical pinning and less often non-operatively as described by Blount. The objective of this study was to assess the clinical and radiological outcomes of Gartland typexa0III supracondylar fractures treated at least 3xa0years earlier using Blounts method.nnnHYPOTHESISnBlounts method produces good outcomes after more than 3xa0years when used to treat Gartland typexa0III supracondylar fractures of the humerus.nnnMETHODSnA single-centre retrospective study was done in paediatric patients who were seen within 24hours after sustaining a Gartland typexa0III supracondylar fracture then re-evaluated at least 36xa0months after treatment. Closed reduction was performed either in the operating room under general anaesthesia or in the radiology suite under procedural sedation. The upper limb was then immobilised for 4xa0weeks using the cuff-and-collar method described by Blount (mean elbow flexion, 134°). The child was evaluated and radiographs obtained at the outpatient clinic on daysxa07 and 14. Functional outcomes were assessed using the 1962xa0SoFCOT criteria and Flynns criteria and the radiological outcome using Baumanns angle, the humero-condylar angle, and distal fragment rotation. From 2009 to 2013, 22xa0patients met the inclusion criteria. Mean follow-up was 57xa0months.nnnRESULTSnClinical outcomes assessed using the 1962xa0SoFCOT criteria were very good in 15xa0patients and good in the remaining 7xa0patients. The rate of satisfactory outcomes according to Flynns criteria was 100%. At last follow-up, mean Baumanns angle was 68°, mean humerocondylar angle was 42°, and 2xa0patients had residual rotation of the distal fragment.nnnCONCLUSIONnThis work confirms the effectiveness of Blounts method for treating Gartland typexa0III supracondylar fractures. We advocate routine first-line treatment of these fractures using Blounts method in the absence of vascular compromise and instability.nnnLEVEL OF EVIDENCEnIV, retrospective study.

Too-long calcaneal process: Results of surgical treatment and prognostic factors.

INTRODUCTIONnThe too-long anterior process (TLAP) can be responsible for ankle pain or repeated sprains in children or adolescents. The objective of this study was to assess the results of TLAP surgical treatment and to analyze influencing factors in case of this surgerys failure.nnnMATERIAL AND METHODSnRetrospective single-center study conducted from 2009 to 2012 including all patients under 18xa0years of age for a TLAP with follow-up equal to or longer than 1xa0year. The results of surgical treatment were assessed using the AOFAS score. Failure was defined as no significant improvement in the AOFAS score at the last follow-up.nnnHYPOTHESISnPredictive factors of the result of surgical treatment for TLAP can be identified.nnnRESULTSnAt the mean follow-up of 2.5xa0years, 35 patients (43 feet) fulfilled the inclusion criteria. Thirteen feet (30%) presented surgical failure. According to the AOFAS score, the results were excellent in 30 feet (70%), good in four (9%), fair in five (12%), and poor in four (9%). Surgical failure was influenced by the patients age at the onset of symptoms and at the time of surgery, the degree of functional limitation, the duration of symptoms before surgery, the number of sprains, and gender (P<0.05).nnnCONCLUSIONnFirstly, in this pediatric population with its high functional demand, the overall rate of failure of TLAP surgery was 30%. Secondly, the factors associated with failure demonstrated made it possible to identify the ideal patient for this surgery: male, with symptom onset between 7 and 10xa0years of age, who had experienced fewer than 15 sprains, and undergone surgery in the 3xa0years following the beginning of symptoms.nnnLEVEL OF EVIDENCEnIV.

Can Gartland II and III supracondylar humerus fractures be treated using Blount's method in the emergency room?

BACKGROUNDnStudies have established that Blounts method is reliable for treating extension supracondylar fractures (SCFs) in paediatric patients. Reduction in the emergency room (ER) under procedural sedation followed by orthopaedic treatment is increasingly used for many fracture types. The primary objective of this study was to determine whether SCF reduction in the ER was feasible, by determining the failure rate. The secondary objective was to identify causes of failure with the goal of improving patient selection to reduction in the ER.nnnHYPOTHESISnGartland II and III SCFs (Lagrange-Rigault grades 2-4) can be treated in the emergency room under fluoroscopic guidance and with procedural sedation.nnnMATERIAL AND METHODSnA retrospective study was conducted in 128 paediatric patients who underwent ER reduction of an SCF in 2014-2015. Mean age was 5.6 years. Reduction was performed either by an orthopaedic surgery resident or by a specially trained emergency physician.nnnRESULTSnOf the 128 SCFs, 101 (79%) were Gartland II and 27 Gartland III. In the Lagrange-Rigault classification, 55 (43%) fractures were grade 2, 59 (46%) were grade 3, and 14 (11%) were grade 4. The arm was immobilised using the cuff-and-collar method described by Blount for 4 weeks. All 128 fractures healed without delay. Blounts method alone was effective in 112 (87.5%) patients. Of the 16 other patients, 15 (Lagrange-Rigault 3, n=14; and 4, n=1) had an unstable fracture after ER reduction and were managed by reduction and internal fixation in the operating room. The remaining patient (0.5%) experienced secondary displacement requiring revision surgery in the operating room.nnnCONCLUSIONnSCFs grades 2 to 4 in the Lagrange-Rigault classification (Gartland II and III) can be treated in the ER by specially trained physicians. Lagrange-Rigault grade 3/Gartland III SCFs are more likely to require subsequent internal fixation but do not contraindicate reduction in the ER.nnnLEVEL OF EVIDENCEnIV, retrospective study.

Cobalt-chrome and titanium alloy rods provide similar coronal and sagittal correction in adolescent idiopathic scoliosis

BACKGROUNDnCobalt-chrome (CoCr) and the titanium alloy TA6V (Ti) are the materials most widely used for spinal instrumentations in patients with adolescent idiopathic scoliosis (AIS). The objective of this work was to compare the effectiveness of CoCr and Ti rods in terms of coronal and sagittal correction by pedicle screw constructs in patients with AIS.nnnHYPOTHESISnCorrection is similar with CoCr and Ti rods in patients with AIS.nnnMATERIAL AND METHODnA retrospective single surgeon study was conducted in patients with AIS managed using pedicle screw posterior spinal fusion with high implant density and reduction by postero-medial translation. Follow-up was more than 2 years in all patients. Patients were divided into two groups based on whether the rods used were made of CoCr (n=30) or Ti (n=33). The groups were identical for age, Risser classification, follow-up duration, type of curve, and implant density. Coronal and sagittal parameters on standing full-spine radiographs were analysed using graphics software before surgery then 1 month after surgery and at last follow-up. Quantitative data were compared by applying Students t test.nnnRESULTSnThe percentage of main curve correction at last follow-up was the same in the two groups (76%/75%) (p=0.7). Gains in thoracic kyphosis (12°/13°) and lumbar lordosis (8°/10°) were not significantly different between groups. At last follow-up, 3 patients had proximal junctional kyphosis, 1 in the CoCr group and 2 in the Ti group (p=0.6).nnnCONCLUSIONnFor posterior spinal fusion to treat AIS, with a high density of pedicle screws, correction by translation, and 6 mm rods, CoCr rods and Ti rods produce the same amount of coronal and sagittal correction.nnnLEVEL OF EVIDENCEnIV, comparative retrospective study with no control group.

A simulation model of nail bed suture and nail fixation: description and preliminary evaluation

BACKGROUNDnWounds of the finger nail bed represent a frequent injury, especially in children. Residents often learn nail bed repair on patients without prior training. We aimed to develop and evaluate a low-fidelity simulation model of nail bed repair.nnnMETHODSnThe model consists of a false nail on a plastic finger and a hydrocolloid dressing, which is pasted on the nail bed site and cut horizontally. This model allows nail bed suture and nail fixation. The cost of each model is about

Advanced containment methods for Legg-Calvé-Perthes disease: triple pelvic osteotomy versus Chiari osteotomy

1. Thirty-three doctors evaluated this model on 10 items, rated out of five, concerning the realism, the difficulty of the procedure, and the educational value. The duration of the procedure was also noted. We evaluated the clinical effectiveness by comparing through Fishers exact test the ratio of unsuitable events (revision surgeries, surgical site infections, and complaint letters) on two periods-3 y before and 18 mo after the implementation of this model in our institution, respectively.nnnRESULTSnAverage mark was 4.16/5. The model was considered reliable, reproducible, and realistic. All the testers recognized a big educational value. The overall duration of the procedure averaged 23 min for residents and 11 min for surgeons. We collected 17 unsuitable events out of 84 patients from the period before and 2 out of 54 patients from the period after (Pxa0=xa00.005). Revision surgeries were 10/84 from the period before and 2/54 from the period after (Pxa0=xa00.04).nnnCONCLUSIONSnThe results of the internal and clinical evaluations are encouraging. We suggest integration of this model into the training program of residents.

Qu’attendre de l’hémi-épiphysiodèse de la base du premier métatarsien dans le traitement de l’hallux valgus juvénile ?

Introduction: The goal of intervention in Legg-Calvé-Perthes disease (LCPD) is to prevent femoral head deformation by containing the head within the acetabulum. Currently, surgical containment methods are the mainstay of treatment, and pelvic osteotomies have been shown to be successful. They include triple pelvic osteotomy (TPO), Salter osteotomy, Chiari osteotomy and shelf procedure. The purpose of this study was to compare clinical and radiologic results for Chiari osteotomy and TPO in LCPD. Methods: 29 children treated between 1980 and 2010 for LCPD in 2 centres were reviewed. 19 underwent TPO, and 10, Chiari osteotomy. Two independent observers assessed sequential radiographs and medical data. Each hip was preoperatively classed by clinical data, Catteral, Herring and Salter-Thompson classification, centre-edge angle (CE), and acetabular index (AI). The 2 groups were first tested for their comparability. After surgery the hips were classified by Stulberg classification, CE, AI, Harris Hip Score (HHS) and performance of further surgery. Chiari osteotomy and TPO have been secondary compared on these data by Wilcoxon test. Results: Average follow-up was 4.2 years. The 2 groups were comparable before surgery. At first and last follow-up examination, statistically significantly superior results in patients with TPO regarding Stulberg classification (p = 0.01), AI (p = 0.002), pain (p = 0.02) and function (p = 0.01) in the HHS score were found. No differences were noticed concerning CE angle. Conclusions: In our series, TPO provided better radiologic and clinical outcomes compared to Chiari osteotomy, specially concerning the final Stulberg classification. We concluded that TPO should be preferred when indicated.

Développement et validation d’un modèle basse fidélité pour le traitement du « doigt de porte » chez l’enfant

Introduction l’hallux valgus juvenile (HVJ) est une pathologie frequente qui peut entrainer une gene fonctionnelle quotidienne importante. L’hemi-epiphysiodese de la base laterale du premier metatarsien est une technique recente dont les resultats ont ete peu rapportes. L’objectif de cette etude etait d’evaluer l’efficacite clinique et radiographique de l’hemi-epiphysiodese laterale comme traitement de l’HVJ. Materiel et methodes Nous avons realise une etude retrospective monocentrique. Etaient inclus tous les patients operes pour HVJ par hemi-epiphysiodese, avec un recul clinique et radiologique superieur a 2xa0ans. L’efficacite de la procedure etait evaluee a l’aide du score Hallux Metatarsophalangeal Interphalangeal Scale (HMIS), des angles metatarso-phalangien (AMP), et inter-metatarsien (AIM). L’ensemble des mesures pre- et postoperatoires ont ete comparees. Resultats Vingt-deux pieds (12xa0patients) presentant un HJV ont ete traites par hemi-epiphysiodese laterale entre 2012xa0et 2015. L’âge moyen des patients au moment de l’operation etait de 10xa0ans. Le suivi moyen etait de 42xa0mois. Le score HMIS moyen s’est ameliore de 56 (49xa0a 67) en preoperatoire a 92 (83xa0a 100) au dernier suivi ( p p xa0>xa00,05). Discussion Le score HMIS etait significativement superieur en postoperatoire, avec une amelioration de la douleur et de la gene fonctionnelle au dernier recul. Bien qu’ayant suivi les patients jusqu’a un âge proche de la maturite osseuse du pied, le benefice radiologique a ete cliniquement peu significatif. Nous avons cependant constate une stabilisation des angles AMP et IMA. Conclusion L’hemi-epiphysiodese laterale de la base du premier metatarsien ameliore de facon significative la gene fonctionnelle dans le traitement de l’HVJ, et semble stopper son evolution anatomique.

Intérêt des connecteurs de dérotation dans la correction axiale des scolioses thoraciques idiopathiques de l’adolescent

Introduction Les traumatismes de l’appareil ungueal des doigts (doigt de porte) representent un motif frequent de consultation aux urgences traumatologiques pediatriques, souvent traites par des medecins juniors. Les lesions sont le plus souvent benignes, mais une prise en charge initiale inadaptee peut entrainer des sequelles esthetiques et fonctionnelles. A notre connaissance, il n’existe pas de formation specifique dans le cursus des internes francais. La simulation s’impose progressivement comme mode de formation privilegiee en chirurgie. C’est pour ameliorer l’apprentissage de la suture et du repositionnement de l’ongle que nous proposons un modele de simulation «xa0basse fidelitexa0», reproductible et peu onereux. Materiel et methodes Le modele est constitue d’un kit de suture standard, un faux ongle et un faux doigt sur lequel est fixe un pansement de type Duoderm®. Nous avons teste ce modele aupres de 23xa0medecins, internes de chirurgie (nxa0=xa03), pediatres urgentistes (nxa0=xa012) et internes de pediatrie (nxa0=xa08), dont l’experience en termes de nombre de plaies pulpo-ungueales deja suturees en circonstances cliniques reelles etait notee. L’evaluation a ete faite au moyen d’un questionnaire anonyme, portant sur le realisme global, le realisme de la sensation de la suture, la difficulte de la procedure (50xa0points au total) et l’interet pedagogique (5xa0points). L’analyse des resultats a ete faite en fonction des 2xa0groupes d’operateurs, experimentes (>xa020xa0procedures deja realisees) ou non experimentes ( Resultats Dans les 2xa0groupes, le modele propose a ete considere comme fiable, reproductible et offrant un tres bon degre de realisme dans la realisation des differentes etapes de la reparation du doigt de porte (en moyennexa0: 41/50). Tous les medecins testeurs ont reconnu un grand interet pedagogique (5/5). Conclusion Nos resultats nous conduisent a proposer d’integrer ce modele de doigt de porte dans le cursus de formation des internes lors du stage en chirurgie infantile ou aux urgences pediatriques.

Adolescent idiopathic scoliosis exceeding 70°: a single unit surgical experience

Introduction La correction des scolioses idiopathiques devrait idealement se faire dans les trois plans de l’espace. La correction de la rotation axiale n’est pas obtenue par les techniques classiques d’instrumentation et reduction. La technique de derotation vertebrale directe permet une derotation partielle mais au prix d’une aggravation de l’hypocyphose thoracique. Un connecteur specifique pour la derotation vertebrale a ete recemment ajoute a la technique de reduction par translation simultanee sur 2xa0tiges (ST2R). Hypothesexa0: l’utilisation de connecteurs de derotation dans le traitement chirurgical des scolioses idiopathiques de l’adolescent par technique ST2R ameliore la correction axiale. Materiel et methodes Etude retrospective, monocentrique, incluant des patients de 2005 a 2015 ayant une scoliose idiopathique Lenke 1 a 4, operes par technique ST2R. La rotation axiale intervertebrale etait mesuree entre la vertebre apicale et la vertebre neutre sur scanner pre- et postoperatoire selon la methode de mesure de Aaro. Le critere de jugement principal etait la difference entre la rotation intervertebrale postoperatoire et preoperatoire. Utilises sur les vertebres autour de l’apex, et sur les 2 tiges, les connecteurs de derotation sont verrouilles en premier sur la tige concave dans le but d’obtenir une translation anteroposterieure plus importante du cote concave que du cote convexe, permettant une rotation des vertebres apicales autour de la tige convexe. Deux series ont ete etudieesxa0: sans connecteur de derotation D− ( n xa0=xa024), avec connecteur de derotation D+ ( n xa0=xa044). Resultats Les groupes etaient comparables et homogenes en termes d’âge, de sexe et de type de scoliose. Le gain moyen de torsion axiale dans le groupe D+ etait de 23xa0% (+3,84°, IC 95xa0%xa0: +1,95 a +5,73). Dans le groupe D−, on retrouvait une perte de torsion axiale moyenne de 4xa0% (−0,42°, IC 95xa0%xa0: −1,19 a +2,03). Les resultats etaient significativement differents entre les 2 groupes ( p xa0=xa00,005). La correction coronale de la courbure principale (Cobb) etait de 80xa0% dans le groupe D+ et de 64xa0% dans le groupe D− ( p p xa0=xa00,3). Conclusion L’utilisation de connecteur de derotation dans le traitement chirurgical des scolioses idiopathiques thoraciques de l’adolescent ameliore significativement la correction axiale et coronale sans porter prejudice au plan sagittal.